Report on Medicare Compliance

  1. CMS: HHAs Can Bill Separately for Vaccines Given at Visits; Beware Penalty for Late RAPs

    Report on Medicare Compliance Volume 30, Number 14. April 12, 2021  | Author: Nina Youngstrom  | April 12, 2021 

    Like many people who called into CMS’s COVID-19 office hours April 6—the last in a series that have helped providers decipher pandemic coding and billing rules—a caller from a hospital system with a home health agency (HHA) asked about the mechanics of vaccine billing. How should the HHA bill for the vaccine when it’s administered to home health patients during the 60-day episode of care, and could the nurse also vaccinate caregivers while in the patient’s home?...

  2. Doctor Is Accused of Cheating Three COVID-19 Relief Funds, Redirecting Medicare Payments

    Report on Medicare Compliance Volume 30, Number 14. April 12, 2021  | Author: Nina Youngstrom  | April 12, 2021 

    After allegedly cheating three COVID-19 relief programs—the Provider Relief Fund, COVID-19 Accelerated and Advance Payments and the Paycheck Protection Program (PPP)—a Colorado physician was charged with theft in connection with health care and other crimes, the Department of Justice (DOJ) said April 8.[1] On top of that, the physician, Francis F. Joseph of Highlands Ranch, allegedly had the Medicare administrative contractor (MAC) switch the bank account for Medicare payments to his former medical group so he could grab the money, according to the grand jury indictment.[2] The physician spent his allegedly ill-gotten gains on travel and home improvements, among other...

  3. Prior Auth of Cardiac Implants Is Added for Inpatients by United; Claims Seen at Risk

    Report on Medicare Compliance Volume 30, Number 14. April 12, 2021  | Author: Nina Youngstrom  | April 12, 2021 

    Under a UnitedHealthcare policy,[1] hospitals are now required to get prior authorization for electrophysiology implants after patients already are approved for inpatient admissions. Some experts find it unnerving because they say cardiac interventions potentially could be delayed while hospitals wait for prior authorization, and they may lose payments when they perform urgent procedures without the commercial payer’s say-so. The policy is seen as another example of health plans layering on processes “in an attempt to deny high-cost services,” an attorney said...

  4. Entities Deal With More Data Outside HIPAA; ‘We Are Seeing Tensions’

    Report on Medicare Compliance Volume 30, Number 14. April 12, 2021  | Author: Nina Youngstrom  | April 12, 2021 

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  5. CMS Open Payment Registry Review Checklist

    Report on Medicare Compliance Volume 30, Number 14. April 12, 2021  | Author: Nina Youngstrom  | April 12, 2021 

    Here’s a checklist to help health care organizations identify conflicts of interest with data provided by CMS’s open payments program and the warnings from the HHS Office of Inspector General’s special fraud alert on speaker programs.[1] It was developed by the consulting firm PYA. Shannon Sumner, PYA’s chief compliance officer, said PYA has encountered some best practice controls in its audits of open payments for health systems:...

  6. CMS Transmittals and Federal Register Regulations, April 2-8, 2021

    Report on Medicare Compliance Volume 30, Number 14. April 12, 2021  | April 12, 2021 

  7. News Briefs: April 12, 2021

    Report on Medicare Compliance Volume 30, Number 14. April 12, 2021  | Author: Nina Youngstrom  | April 12, 2021 

    ◆ Doctors Care P.A., the largest urgent care provider network in South Carolina, and its management company, UCI Medical Affiliates of South Carolina Inc., will pay $22.5 million to settle false claims allegations, the U.S. Attorney’s Office for the District of South Carolina said April 8.[1] Doctors Care and UCI allegedly falsely certified that some urgent care visits were performed by providers who were credentialed to bill Medicare, Medicaid and TRICARE, which means the services weren’t performed by credentialed providers from 2013 to 2018, according to the complaint, the U.S. attorney’s office alleged. The case was set in motion by...

  8. OIG Audit: Hospital was Overpaid $23.6M, Mostly for IRF Claims; It Will Appeal Denials

    Report on Medicare Compliance Volume 30, Number 13. April 05, 2021  | Author: Nina Youngstrom  | April 05, 2021 

    In possibly its largest overpayment finding ever in a provider compliance audit, the HHS Office of Inspector General (OIG) said Sunrise Hospital & Medical Center in Las Vegas, Nevada, was overpaid $23.6 million in 2017 and 2018, according to a report posted April 1.[1] The lion’s share of the overpayment stemmed from inpatient rehabilitation facility (IRF) admissions, although some were for inpatient admissions that should have been billed as outpatient or observation services, OIG said. The hospital “strongly disagrees with the vast majority of OIG’s conclusions” and its use of extrapolation and plans to appeal all denied IRF claims...

  9. Without a Diagnostic Test for Acute Heart Failure, Payers Push Claim Denials, M.D. Says

    Report on Medicare Compliance Volume 30, Number 13. April 05, 2021  | Author: Nina Youngstrom  | April 05, 2021 

    After a 66-year-old woman with chronic heart failure and kidney disease showed up at the hospital wheezing and with chest pressure and congestion, she was admitted as an inpatient. Her diagnosis was acute diastolic heart failure and acute kidney injury, and the hospital billed for MS-DRG 291, heart failure and shock with acute diastolic heart failure as the only major complication or comorbidity (MCC). But the payer removed the MCC, which resulted in a lower-paying version of the MS-DRG. Like many denials for acute heart failure, it was eminently appealable. All the documentation supporting acute heart failure was there, including...

  10. CMS Resumes Routine Hospital CoP Surveys, Expect In-Person Visits

    Report on Medicare Compliance Volume 30, Number 13. April 05, 2021  | Author: Nina Youngstrom  | April 05, 2021 

    After some stops and starts, surveys of hospital compliance with the Medicare conditions of participation and other regulations are returning to normal, more or less. In a March 26 memo[1] to state survey agency directors, CMS said “all onsite revisits are authorized and should resume.” Surveys have been limited mostly to infection control and immediate jeopardy (the risk of death or harm to a patient) during the COVID-19 public health emergency (PHE). Now they’re opening up, and the usual rules on plans of correction again apply, according to the memo from the directors of the Quality, Safety & Oversight Group...

  11. Integration Chart: Government Entities With Medicare Responsibilities

    Report on Medicare Compliance Volume 30, Number 13. April 05, 2021  | Author: Nina Youngstrom  | April 05, 2021 

    Here’s a snapshot of the different Medicare watchdogs and some of the other government agencies that oversee health care organizations. It was developed by Frank Mesaros, manager of compliance risk & facility audits at WellSpan Health in York, Pennsylvania, to help employees get a better sense of the differences among them. “We found it helpful when looking at an issue and thinking about all the possible implications and who might be responsible for oversight,” added Wendy Trout, director of corporate compliance at WellSpan. Contact Mesaros at fmesaros@wellspan.org and Trout at wtrout@wellspan.org...

  12. MACs to Hold Claims While Waiting for Final Bill on Sequester Cut

    Report on Medicare Compliance Volume 30, Number 13. April 05, 2021  | Author: Nina Youngstrom  | April 05, 2021 

    Medicare claims will be in suspended animation temporarily, as CMS waits for Congress to finalize legislation to prevent a 2% across-the-board payment cut to providers. CMS has instructed Medicare administrative contractors (MACs) to hold all claims with dates of services on or after April 1, 2021, for a short time until the fate of the moratorium of the so-called sequester cut is clear, “without affecting providers’ cash flow,” according to a March 31 special edition MLN Connects.[1]...

  13. CMS Transmittals and Federal Register Regulations, March 26-April 1, 2021

    Report on Medicare Compliance Volume 30, Number 13. April 05, 2021  | April 05, 2021 

  14. News Briefs: April 5, 2021

    Report on Medicare Compliance Volume 30, Number 13. April 05, 2021  | Author: Nina Youngstrom  | April 05, 2021 

    ◆ Because of the COVID-19 pandemic, CMS said April 1 that it won’t update the 855 enrollment form with sections on “affiliation disclosures,” as planned in a 2019 program integrity regulation,[1] “for at least another 12 months,” according to MLN Matters (SE21003).[2] It also will adopt a phased-in approach to affiliation disclosures. The regulation, which implements provisions of the Affordable Care Act, is designed to keep, or kick, providers out of Medicare if they pose an “undue risk” of fraud, waste or abuse. It requires providers to disclose “affiliations” with other providers who have been suspended or excluded from Medicare,...

  15. Providers Risk Recoupment or Worse for PRF Noncompliance; Consider a Mock Audit

    Report on Medicare Compliance Volume 30, Number 12. March 29, 2021  | Author: Nina Youngstrom  | March 29, 2021 

    The consequences for providers may be serious if they run afoul of the terms and conditions and/or reporting requirements of the Provider Relief Fund (PRF), attorneys said. They may find out soon, as multiple audits of PRF money disbursed to providers are underway or looming, and the director of audit at the HHS Office of Inspector General (OIG) said there’s a possibility of a separate audit of balance billing, which is one of the PRF terms and conditions. Meanwhile, providers are still waiting to hear from HHS about certain reporting deadlines and a process for returning unused PRF money...

  16. After Settlement, Court OKs Some Whistleblower Allegations That DOJ Declined in Sutter Case

    Report on Medicare Compliance Volume 30, Number 12. March 29, 2021  | Author: Nina Youngstrom  | March 29, 2021 

    Sixteen months after Sutter Health settled a false claims case with the Department of Justice (DOJ) over some of the allegations in a 2014 whistleblower complaint about physician arrangements, other allegations that DOJ declined to pursue are back in play. A federal court March 17 gave the whistleblower, a former compliance officer at Sutter Medical Center in Sacramento, the go-ahead to proceed with certain allegations of reverse false claims and overly generous compensation arrangements, while dismissing other allegations.[1]...

  17. OCR: Right of Access Fictions Persist; 17th Settlement Announced

    Report on Medicare Compliance Volume 30, Number 12. March 29, 2021  | Author: Nina Youngstrom  | March 29, 2021 

    Some covered entities (CEs) refuse to give patients access to their medical records until their bills are paid potentially in violation of the HIPAA privacy rule, according to a top official from the HHS Office for Civil Rights (OCR)...

  18. An Evolution in Pie Charts: How Breaches Have Changed

    Report on Medicare Compliance Volume 30, Number 12. March 29, 2021  | Author: Nina Youngstrom  | March 29, 2021 

    Serena Mosley-Day, senior advisor of HIPAA compliance and enforcement at the HHS Office for Civil Rights, said the reasons for HIPAA breaches have shifted, with a surge in breaches caused by hacking. She spoke at the Virtual Thirtieth National HIPAA Summit[1] March 22.[2]...

  19. OIG: Providers May Need Flexibility; Some Self-Disclosures Were Paused

    Report on Medicare Compliance Volume 30, Number 12. March 29, 2021  | Author: Nina Youngstrom  | March 29, 2021 

    The HHS Office of Inspector General (OIG) has been cutting providers some slack during the COVID-19 public health emergency, a top official said. That has extended, for example, to suspending penalties for telehealth copay waivers[1] and setting aside specific corporate integrity agreement (CIA) requirements in 30 instances...

  20. CMS Transmittals and Federal Register Regulations, March 19-25, 2021

    Report on Medicare Compliance Volume 30, Number 12. March 29, 2021  | March 29, 2021 

  21. News Briefs: March 29, 2021

    Report on Medicare Compliance Volume 30, Number 12. March 29, 2021  | Author: Nina Youngstrom  | March 29, 2021 

    ◆ Bradley J. Harris, the former CEO of Novus and Optimum Health Services, a hospice in Texas, pleaded guilty to conspiracy to commit health care fraud, the U.S. Attorney’s Office for the Northern District of Texas said March 19.[1] He faces up to 10 years in prison. Harris admitted he billed Medicare and Medicaid for hospice services that weren’t provided, that were not directed by a medical professional, or that were rendered to patients who were not eligible for hospice care. He also admitted to using blank, presigned controlled substance prescriptions he got from three physicians to hand out drugs...

  22. PBDs May Want to Delay Refunds in Mid-Build Audit, Lawyer Says; Adjustments Are Tricky

    Report on Medicare Compliance Volume 30, Number 11. March 22, 2021  | Author: Nina Youngstrom  | March 22, 2021 

    Hospitals with provider-based departments (PBDs) that failed CMS’s audit[1] on the mid-build exception might want to sit on their overpayments, an attorney said. It’s conceivable CMS under the Biden administration will reconsider the audit findings, which would be a relief both in terms of the money and in terms of what two compliance professionals said is the nightmare of sorting through claims to determine which have to be adjusted...

  23. CMS: No MSP Waiver for COVID-19 Vaccines, But There’s a Shortcut; CMS Increases Payment

    Report on Medicare Compliance Volume 30, Number 11. March 22, 2021  | Author: Nina Youngstrom  | March 22, 2021 

    Although it may slow the process of putting COVID-19 shots in arms, hospitals are required to complete the Medicare as Secondary Payer (MSP) questionnaire or a version of it when administering the vaccine. There’s no waiver for finding out whether Medicare is the primary payer, a CMS spokesperson said, although CMS two years ago provided a shortcut...

  24. Provider Wins $2M Appeal at ALJ Over Modifier 25, Random Sample

    Report on Medicare Compliance Volume 30, Number 11. March 22, 2021  | Author: Nina Youngstrom  | March 22, 2021 

    A cancer center has won its appeal of $2 million in Medicare claim denials in a case about modifier 25 and the extrapolation of an overpayment. Problems with the random sample underlying the extrapolation helped win the day, according to the March 2 decision by an administrative law judge (ALJ)...

  25. Before It’s Too Late: Ensuring BA, Subcontractor Compliance

    Report on Medicare Compliance Volume 30, Number 11. March 22, 2021  | Author: Theresa Defino  | March 22, 2021 

    Sometime during the fall, a worker for a subcontractor of Humana Inc. decided to share member information from medical records via a Google document with people he was training to be medical coders, part of his attempt to run a “personal coding business endeavor.”[1]...